Use of an adherent fenestrated drape to anchor an adjacent vertical sterile surgical towel.

Vertical surgical sites or those on reclining patients often present a challenge when establishing and securing a sterile field. The drape or towel most proximal to the physician is often vertically oriented. The forces of gravity and movements of surgery can shift or detach this vertical drape. Sterile clamps are not always available or are needed for securing other instruments. We present a method to secure this vulnerable drape using a central fenestrated adherent drape.

Economic Costs Avoided by Diagnosing Melanoma Six Months Earlier Justify >100 Benign Biopsies.

New melanoma drugs bring enormous benefits but do so at significant costs. Because melanoma grows deeper and deadlier over time, deeper lesions are costlier due to increased sentinel lymph node biopsy, chemotherapy, and disease-associated income loss. Prior studies have justified pigmented lesion biopsies on a "value per life" basis; by contrast we sought to assess how many biopsies are justified per melanoma found on a purely economic basis. We modeled how melanomas in the United States would behave if diagnosis were delayed by 6 months, eg, not biopsied, only observed until the next surveillance visit. Economic loss from delayed biopsy is the obverse of economic benefit of performing biopsy earlier. Growth rates were based on Liu et al. The results of this study can be applied to all patients presenting to dermatologists with pigmented skin lesions suspicious for melanoma. In-situ melanomas were excluded because no studies to date have modeled growth rates analogous to those for invasive melanoma. We assume conservatively that all melanomas not biopsied initially will be biopsied and treated 6 months later. Major modeled costs are (1) increased sentinel lymph node biopsy, (2) increased chemotherapy for metastatic lesions using increased 5-yr death as metastasis marker, and (3) income loss per melanoma death at $413,370 as previously published. Costs avoided by diagnosing melanoma earlier justify 170 biopsies per melanoma found. Efforts to penalize "unnecessary" biopsies may be economically counterproductive.

J Drugs Dermatol. 2016;15(5):527-532.

Safe and efficacious use of intralesional steroids for the treatment of focally resistant mycosis fungoides.

Cutaneous T-cell lymphoma is a cancer of skin-homing T cells, of which mycosis fungoides (MF) is the most common variant. MF treatments range from topical steroids to systemic chemotherapy. Resistant cutaneous MF nodules can present a special challenge in that typical topical therapies may not penetrate thick lesions, and increasing systemic therapy brings added risk of side effects. We report successful use of intralesional steroids (ILS) for treatment-resistant MF, including tumor-stage plaques and nodules in 4 consecutive patients with focally resistant MF. ILS have been widely used to treat a broad range of cutaneous conditions such as alopecia areata and keloids. Side effects of ILS include hypopigmentation, atrophy, telangiectasias, lilac discoloration, acne, and striae. Rarely, and in circumstances involving unusually large doses, ILS may cause Cushing's syndrome, hypothalamus-pituitary-adrenal axis suppression, and reduced bone mineral density. The MF patients tolerated treatment well without any of the above side effects other than local hypopigmention in a single patient. These results point toward further exploration into ILS as a treatment for focally resistant MF.

Cutaneous adenosquamous carcinoma: a rare neoplasm with biphasic differentiation.

Cutaneous adenosquamous carcinoma (cASC) is an extremely rare malignant neoplasm. Due to its disputed pathophysiology, ambiguity of presentation, and lack of definitive clinical research, cASC is a commonly misdiagnosed skin lesion. Although it is not commonly encountered in clinical practice, it is essential for clinicians to correctly recognize and treat cASC because of its malignant and recurrent nature. The images provided in this case report depict classic and complete presentation of cASC. A review of the literature also was conducted to provide insight into this rare atypical lesion.

Cetirizine-induced acute generalized exanthematous pustulosis: a serious reaction to a commonly used drug.

Acute generalized exanthematous pustulosis (AGEP) is an abrupt cutaneous adverse reaction usually in response to medications. It is generally a self-limiting disease if diagnosed promptly and the offending agent discontinued. Cetirizine, a commonly used anti-histamine medication for the treatment of allergic diseases has few reported side effects and is normally well-tolerated and effective. Herein, the first reported case of cetirizine induced AGEP is presented, followed by a discussion of the clinical and pathological aspects of this adverse cutaneous reaction to a widely used drug. Awareness of this reaction is vital owing to the extensive use of cetirizine and the importance of drug cessation once the reaction is identified. Lastly, other pustular cutaneous reactions may present similarly and therefore accurate identification of this disease can prevent unnecessary diagnostic testing.

Early treatment with nonsucrose intravenous immunoglobulin in a burn unit reduces toxic epidermal necrolysis mortality.

BACKGROUND: Intravenous immunoglobulin (IVIG) can be used to treat potentially deadly toxic epidermal necrolysis (TEN), milder Stevens Johnson Syndrome (SJS) and intermediate TEN/SJS overlap. Some formularies now deny IVIG for TEN based on the EuroSCAR TEN/SJS study that reported a nonsignificant trend toward increased mortality in 75 IVIG-treated TEN/SJS patients; of note the IVIG patients had more TEN and less SJS than patients in other treatment arms. EuroSCAR data on mortality among the 25 IVIG-treated TEN patients, use of nonsucrose IVIG, and admission to specialized settings such as burn units was not disclosed. The impact of treatment setting (specialized unit vs general ward) on IVIG efficacy has not previously been studied. OBJECTIVE: To evaluate efficacy of treating TEN with early nonsucrose IVIG in a burn unit. METHODS: Data were retrospectively collected from 13 IVIG-treated TEN patients admitted to a burn unit over a 6-year period. RESULTS: We report 0% mortality among 13 IVIG-treated TEN patients. Mortality was significantly lower than predicted by SCORTEN. Mortality was also significantly lower than the EuroSCAR groups receiving IVIG (P<.005), supportive care (P<.018), and corticosteroids only (P<.046). CONCLUSION: TEN patients may benefit from early nonsucrose IVIG administered in burn units or other specialized settings.

Consumption of polyphenol plants may slow aging and associated diseases.

Slowing aging is a widely shared goal. Plant-derived polyphenols, which are found in commonly consumed food plants such as tea, cocoa, blueberry and grape, have been proposed to have many health benefits, including slowing aging. In-vivo studies have demonstrated the lifespan-extending ability of six polyphenol-containing plants. These include five widely consumed foods (tea, blueberry, cocoa, apple, pomegranate) and a flower commonly used as a folk medicine (betony). These and multiple other plant polyphenols have been shown to have beneficial effects on aging-associated changes across a variety of organisms from worm and fly to rodent and human.

Atopic dermatitis in children in the United States, 1997-2004: visit trends, patient and provider characteristics, and prescribing patterns.

OBJECTIVE: Atopic dermatitis is the most common chronic inflammatory skin disease of childhood and is increasing in prevalence throughout the world. Morbidity and resource use for atopic dermatitis are comparable to other chronic diseases. Topical corticosteroids are first-line therapeutic agents for atopic dermatitis; topical calcineurin inhibitors are considered second-line agents for patients who are older than 2 years. The aims of this study were to examine trends in visits for atopic dermatitis in children in the United States between 1997 and 2004, identify factors that were associated with a pediatric visit for atopic dermatitis, and assess changes in the treatment of atopic dermatitis over time. METHODS: Visits for atopic dermatitis by children (0-18 years) to office-based physicians and hospital outpatient departments using 1997-2004 National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey databases were analyzed. Medication prescribing rates during 2 time periods (1997-2000 and 2001-2004) were also analyzed. RESULTS: There were an estimated 7.4 million visits for atopic dermatitis. Statistically significant differences in patients with atopic dermatitis included age 2 to 5 years, black race, Asian race, and specialist or hospital outpatient clinic evaluation. The increase in atopic dermatitis visits per year was statistically significant. No statistical differences in prescribing rates were identified between the 2 time periods. Between 1997 and 2000, topical corticosteroids were prescribed in 34% of visits, decreasing to 25% between 2001 and 2004. Between 2001 and 2004, topical calcineurin inhibitors were prescribed in 23% of visits. In the same period, topical corticosteroids were prescribed in 24% of visits by children who were younger than 2 years; topical calcineurin inhibitors were prescribed in 22% of visits. CONCLUSIONS: Visits for atopic dermatitis in children are increasing. A recommended first-line treatment was prescribed in a minority of the visits.